Endoscopic retrograde cholangiography versus peroral cholangioscopy to evaluate intraepithelial tumor spread in biliary cancer.

BACKGROUND AND STUDY AIMS: Localized-type bile duct carcinoma (LBDC) is often accompanied by extensive intraepithelial tumor spread (ITS) of 2 cm or more, which makes radical resection more difficult. This retrospective case review compares the diagnostic accuracy of endoscopic retrograde cholangiography (ERC) and peroral cholangioscopy (POCS) to detect ITS beyond the visible LBDC. PATIENTS AND METHODS: Forty-four consecutive patients with LBDC diagnosed between April 2004 and October 2008 who underwent radical resection with histopathological analysis were included in this study. Extensive ITS was found histopathologically in one-third of the cases (32 %). The outcome parameters were the presence or absence of extensive ITS and the extent of extensive ITS proximal and distal to the main tumor. RESULTS: In six cases it was not possible to pass the cholangioscope through the tumor sites. ERC correctly identified the presence of extensive ITS in 11/14 cases and did not yield any false-positive results. The three cases in which ERC was negative were all correctly identified by POCS plus biopsy since the cholangioscope could be passed in all three cases. The extent of extensive ITS was correctly diagnosed by ERC alone, ERC with POCS, and ERC with POCS plus mapping biopsy in 22 %, 77 %, and 100 % of cases, respectively. CONCLUSIONS: The presence of extensive ITS was correctly detected in 80 % of cases by ERC alone. POCS with mapping biopsy provided perfect diagnostic accuracy not only of the presence or absence but also of the extent of extensive ITS. However, POCS has the limitation that the cholangioscope cannot be passed through the tumor sites in approximately 15 % of cases.

Persistent clonal proliferation of human T-lymphotropic virus type I-infected cells in vivo.

Clonal proliferation of human T-lymphotropic virus type I (HTLV-I)-infected cells has been detected by Southern blot analysis and inverse PCR in patients with adult T-cell leukemia, patients with HTLV-I-associated diseases, and even in asymptomatic carriers. Combining inverse PCR with long PCR, we amplified the genomic DNA regions flanking the integration sites of the HTLV-I provirus to detect clones of infected cells. Inverse long PCR revealed that increased virus load was associated with an increase of both the number of cells in each clone and the number of clones. Clonal proliferations were found in both CD4- and CD8-positive cells in a carrier and a patient with HTLV-I-associated neuropathy/tropical spastic paraparesis. These HTLV-I-infected clones persisted over several years in the same carriers, and, moreover, most of the persistent clones were CD4 positive in a HTLV-I carrier. These findings indicate that HTLV-I infection plays an important role in the clonal expansion of lymphocytes and the prolonged survival of CD4-positive cells in vivo. Surviving T-lymphocytes may be susceptible to genetic changes, leading to the onset of leukemia.

Random integration of HTLV-1 provirus: increasing chromosomal instability.

Adult T-cell leukemia/lymphoma (ATLL) is a neoplasm of mature helper (CD4) T-lymphocytes. Human T-cell lymphotropic virus type-I (HTLV-I) is etiologically considered to cause ATLL. It has been suggested that HTLV-I integrates its provirus into random sites in host chromosomal DNA after infection. Clonal integration has been observed in patients with ATLL, including smoldering, chronic and acute leukemia states. Almost all cases with ATLL demonstrate clonal chromosome abnormalities, with karyotypes being very complicated in both number and structure. However, there are no specific karyotype abnormalities in ATLL. In order to examine the role of HTLV-I in the pathogenesis of ATLL, we investigated whether or not HTLV-I randomly integrates and whether the integration site in the human genome is associated with any chromosomal abnormality. We analyzed 18 cases with ATLL, which included 15 cases with acute states, two cases with chronic states and one case with a smoldering state. In four of the 18 cases, the HTLV-I provirus integrated into the 9th chromosome, while in three cases, it integrated into the 1st or 10th chromosome. However, the integrated site in the chromosome varied in each case and the random integration was considered to be true. All 15 cases with acute ATLL had complicated chromosomal abnormalities and two cases with chronic and smoldering ATLL showed simple abnormal karyotypes, while one case with chronic ATLL showed a normal karyotype. In 15 of the 18 cases, the chromosomes with HTLV-I integration showed abnormalities. In particular, in two cases with simple chromosome abnormalities, HTLV-I integrated into the abnormal chromosome, but not into the normal chromosome. The HTLV-I proviral integration thus seems to be associated with chromosome abnormalities. In the multistage leukemogenesis of ATLL, these findings indicate that HTLV-I integration might play an important role in the induction of chromosomal instability.

Influence of immobilization upon calcium metabolism in the week following hemiplegic stroke.

Hip fractures on the paretic side are a serious post-stroke complication and may result from disuse hemiosteopenia, hypovitaminosis D, and an increasing risk of falls. To evaluate short-term immobilization effects, we assessed calcium metabolism in 89 patients 1 week after the hemiplegic stroke and in 36 controls. Patient activity was rated using the Barthel index (BI). Sera from stroke patients and control subjects were assayed for ionized calcium, parathyroid hormone (PTH), 25-hydroxyvitamin D (25-OHD), 1, 25-dihydroxyvitamin D (1,25-(OH)(2)D), bone Gla protein (BGP; a bone formation marker) and pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP; a bone resorption marker). Patients' serum concentrations of ionized calcium and ICTP were higher than in controls and correlated negatively with BI; their BGP concentrations were low, correlating positively with BI. Concentrations of serum 25-OHD, 1,25-(OH)(2)D, and PTH also were low; serum 25-OHD was at a deficient level (<10 ng/ml) in nine patients (10%), an insufficient level (10-20 ng/ml) in 56 (63%), and a sufficient level (>20 ng/ml) in only 24 (27%). PTH correlated negatively with calcium and 1,25-(OH)(2)D. Hypovitaminosis D is common in acute stroke patients. Immobilization from acute hemiplegia can increase bone resorption and serum calcium, and inhibit PTH secretion and 1,25-(OH)(2)D production to add to the effects of hypovitaminosis D.

Genetic basis of the silent phenotype of serum butyrylcholinesterase in three compound heterozygotes.

Three Japanese patients showed very low butyrylcholinesterase activity in their sera and appeared to be homozygous for silent genes for butyrylcholinesterase. From DNA analysis, all three patients were compound heterozygotes: GGA(Gly) to CGA(Arg) at codon 365 (G365R) and TTC(Phe) to TCC(Ser) at codon 418 (F418S) in patient 1, G365R and CGT(Arg) to TGT(Cys) at codon 515 (R515C) in patient 2 and ACT(Thr) to CCT(Pro) at codon 250 (T250P) and AGA(Arg) to TGA(Stop) at codon 465 (R465X) in patient 3. The K-variant, GCA(Ala) to ACA(Thr) at codon 539, was also found in patients 1 and 2. Simple identification methods for all the mutations were developed and applied to family analysis and control individuals. The mutant alleles (with silent gene and K-variant) were segregated as predicted by theory in pedigrees of patients 1 and 2. Four of the mutations, F418S, R515C, T250P and R465X, were initially discovered in Japan and genetic heterogeneity among the human population for the butyrylcholinesterase gene was suggested.

Classification of potentially toxic chemicals based on their effects on mitochondrial respiration.

The classification of potentially toxic chemicals including environmental pollutants was made with respect to state 3 and state 4 respiration of mitochondria. The concentration of certain metals for 50% inhibition of respiratory control index (RCI; state 3/state 4) was lower than that of organic compounds tested. Various chemicals including environmental pollutants were classified into four groups by combination of effects on state 3 and state 4 respiration.

[DNA stemline heterogeneity as preoperative prognostic factor in esophageal cancer].

Flow cytometric nuclear DNA analysis was performed on 36 preoperative endoscopic biopsy specimens and 89 surgically resected specimens of esophageal carcinomas without preoperative radiotherapy. Carcinomas with aneuploid or DNA stem-line heterogeneity had a higher frequency of lymph node metastasis (p < 0.01). The correspondence rate of nuclear DNA ploidy patterns was 97% between biopsy and resected specimens, and that of heterogeneity was 72%. Though only six cases showed heterogeneity in biopsy specimens out of 12 cases which showed heterogeneity in resected specimens, preoperative detection of heterogeneity was supposed to be more accurate by an increase of biopsy specimens. DNA analysis of biopsy specimens may be a possible indicator of the malignant potential of esophageal carcinoma.

[Supramicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the extremities].

During the past eight years, we treated obstructive lymphedema of a unilateral upper extremity in 27 females and of a unilateral or bilateral lower extremity in 35 males and females with supramicrosurgical lymphaticovenular anastomoses and/or conservative treatment. The most common cause of upper limb edema was mastectomy with or without subsequent radiation therapy for breast cancer, and that of lower limb edema was hysterectomy with radiation. As an objective assessment of edema, the circumferences of the affected and opposite normal forearms or lower legs were measured 10 cm below the olecranon of the arm or the lower border of the patella. In patients who received conservative treatment (12 arms and 12 legs), the average excess circumferential length of the affected arm and leg was 6.4 and 7.1 cm over that of normal extremities, average duration of edema before treatment was 3.5 and 5.2 years, average period for conservative treatment was 10.6 months and 1.5 years, and average decreased circumferential length was 0.8 and 0.6 cm, respectively. The rate of circumferential decrease over 4 cm was none in arm and 16.7% in leg edema. In patients who underwent surgery (12 arms and 16 legs), the average excess circumferencial length was 8.9 and 9.8 cm, average duration of edema before surgery was 8.2 and 8.9 years, average follow-up after surgery was 2.2 and 3.3 years, and average decrease in excess circumference was 4.1 and 2.7 cm, respectively. The rate of circumferential decrease over 4 cm was 58.3% in arms and 50% in legs. These results indicate that supramicrolymphaticovenular anastomoses have a valuable place in the treatment of obstructive lymphedema.

Determination method of optical properties.

A new parameter called the coefficient of reflectivity differentiated with respect to the wavelength of light (dR/dλ) is introduced. This parameter is used to describe a new method of determining the optical properties, a refractive index, and the thickness of nonabsorbent thin films from reflectivity R and a differential coefficient (dR/dλ) for either s-polarized light or p-polarized light. It is also shown that optical properties can be obtained from reflectivity R and a coefficient of reflectivity differentiated with respect to the incident angle of light (dR/dθ).

Development of Babesia ovata in the haemolymph of the tick, Haemaphysalis longicornis.

The haemolymph of adult tick Haemaphysalis longicornis (H. longicornis) infected with Babesia ovata (B. ovata) was examined at regular intervals. As a result kinetes could be detected in the haemolymph 15 days after engorgement. The kinetes detected could be classified into three types on the basis of their morphological characteristics. They increased gradually in number, reaching a maximum 23 days later. Then they tended to decrease in number, disappearing almost completely from the haemolymph 38 days after the engorgement of ticks.

[Stimulative effect of chlordanes on guinea pig polymorphonuclear leukocytes].

To investigate the toxicity of chlordane, an organochlorine insecticide, effects of cis-Chlordane, trans-Chlordane, Heptachlor and Heptachlor epoxide were examined on stimulus responses of guinea pig polymorphonuclear leukocytes (PMNs). Results obtained were as follows. These chlordane-related compounds stimulated superoxide (O2-) generation, altered membrane potential and increased intracellular Ca2+ concentration ((Ca2+]i). As a significant tendency was not found in the stimulating effects of these compounds, the relationship between the effect and molecular structure of these substances remains unknown. Of these response reactions of PMN stimulated by chlordanes, stimulation of O2- generation lagged behind the others. Increase in [Ca2+]i was due to both acceleration of extracellular Ca2+ influx and Ca2+ release from intracellular pool. These results indicate that these chlordane-related compounds stimulate PMN and suggest a causal relationship between the stimulation of O2- generation by these substances and their toxicity.

DNA diagnosis of HTLV-I.

Human T-lymphotropic virus type I (HTLV-I) was the first retrovirus which was directly associated with adult T-cell leukemia (ATL). Infection with HTLV-I can also lead to various other diseases, e.g. HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) and HTLV-I uveitis, possibly via induction of immunodeficiency or hyperreactivity against HTLV-I-infected cells. Epidemiological data have shown that patients who developed these diseases represent a small percentage of HTLV-I-infected individuals living in restricted geographical areas. The identification of HTLV-I-infected individuals using serological and DNA-diagnostic methods is important because knowledge of HTLV-I seropositivity may help to prevent the transmission between sexual partners, as well as transmission from mother to child and blood transfusion. It also assists in establishing a diagnosis of ATL, HAM/ TSP and other HTLV-I-associated diseases.

Prognostic significance of the p53 mutation in esophageal cancer.

In the esophagus, alterations in the p53 tumor suppressor gene are associated with the development of preinvasive neoplastic lesions to invasive carcinoma. The role of p53 gene mutation in the progression of esophageal cancer still remains unclear. In this study, 82 DNA samples extracted from formalin-fixed, paraffin-embedded esophageal cancer tissues were analyzed for p53 mutation by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) analysis. All the patients had been treated surgically and were Japanese. Exons 5 through 8 of the p53 gene were amplified in DNAs and the mutations detected in 28 cases (34%) did not correlate with tumor location, histopathologic classification, histologic depth of tumor invasion, lymph node involvement or clinical stage. Among 39 patients with stage 3 and 4 disease who had undergone radical esophageal resection, those with p53 mutation had a poorer prognosis, the two-year survival being 25.4% compared with 61.2% for those without p53 mutation (P<0.01). These results suggest that p53 gene mutations play an important role not only in the genesis but also the progression of human esophageal cancer.

Development of Babesia ovata in the ovary and eggs of the tick, Haemaphysalis longicornis.

The ovary and eggs of adult tick Haemaphysalis longicornis (H. longicornis) infected with Babesia ovata (B. ovata), were examined at regular intervals of time. As a result kinetes could be detected in the ovary for the first time 6 days after engorgement. The kinetics could be classified into three types on the basis of their morphological characteristics. On the 2nd day after oviposition, round-formed protozoa were found in the ooplasm of the egg. In 5 days after oviposition, these round-formed bodies were transformed into club-forms. On the 9th day after oviposition, the kinetes were observed in the ooplasm. Morphologically, it seemed possible that B. ovata is transmitted by eggs of the tick, H. longicornis.

Two types of defective human T-lymphotropic virus type I provirus in adult T-cell leukemia.

Adult T-cell leukemia (ATL), an aggressive neoplasm of mature helper T cells, is etiologically linked with human T lymphotropic virus type I (HTLV-1). After infection, HTLV-I randomly integrates its provirus into chromosomal DNA. Since ATL is the clonal proliferation of HTLV-I-infected T lymphocytes, molecular methods facilitate the detection of clonal integration of HTLV-I provirus in ATL cells. Using Southern blot analyses and long polymerase chain reaction (PCR) we examined HTLV-I provirus in 72 cases of ATL, of various clinical subtypes. Southern blot analyses revealed that ATL cells in 18 cases had only one long terminal repeat (LTR). Long PCR with LTR primers showed bands shorter than for the complete virus (7.7 kb) or no bands in ATL cells with defective virus. Thus, defective virus was evident in 40 of 72 cases (56%). Two types of defective virus were identified: the first type (type 1) defective virus retained both LTRs and lacked internal sequences, which were mainly the 5' region of provirus, such as gag and pol. Type 1 defective virus was found in 43% of all defective viruses. The second form (type 2) of defective virus had only one LTR, and 5'-LTR was preferentially deleted. This type of defective virus was more frequently detected in cases of acute and lymphoma-type ATL (21/54 cases) than in the chronic type (1/18 cases). The high frequency of this defective virus in the aggressive form of ATL suggests that it may be caused by the genetic instability of HTLV-I provirus, and cells with this defective virus are selected because they escape from immune surveillance systems.

Appendiceal intussusception due to an appendiceal malignant polyp--an association in a patient with Peutz-Jeghers syndrome: report of a case.

A 40-year-old woman with Peutz-Jeghers syndrome and an appendiceal intussusception is reported. In this patient, the lead point was a large sessile, appendiceal polyp. The invaginated and inverted portion of the appendix resembled the long stalk of a pedunculated polyp on roentgenography and endoscopic examination. Histologically, the appendiceal polyp was a villous adenoma with mild to severe atypia and focal carcinoma in situ. In patients with Peutz-Jeghers syndrome, hamartomatous polyps and colorectal adenomatous polyps with highly malignant potential can coexist and must be managed appropriately. Therefore, when evaluating a polypoid or a pedunculated lesion in the cecal lumen, the possibility of an appendiceal intussusception should also be investigated.